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Health Care Fraud and Abuse

Health care fraud is a significant bother for all stakeholders, even though not everyone realizes it. On the one hand, fraud and abuse are associated with an increased cost of care. According to Drabiak and Wolfson (2020), up to 10% of all healthcare costs are associated with fraudulent reimbursement claims. This implies that such fraudulent activities as upcoding or billing for services that were not provided cost the US citizens more than $100 billion a year. On the other hand, fraud means risk to patient safety. For example, there are cases when doctors put elderly patients at health risks by performing unneeded surgeries (Drabiak & Wolfson, 2020). Thus, it is clear that efficient practices are needed to prevent these problems.

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First, the problem should be addressed on the institutional level by adopting a zero-tolerance attitude to fraud and abuse. Adequate workplace culture is the key method for addressing the problem. Second, providers need to hire “qualified quality assurance and compliance personnel and utilizing CMS provider resources that offer ongoing education” (Drabiak & Wolfson, 2020, p. 229). Third, healthcare providers need to provide education to all the healthcare personnel to ensure the highest level of compliance with national requirements of billing and coding. Finally, Drabiak and Wolfson (2020) recommend utilizing the latest technology to address the issue. Front-end analytics using big data and artificial intelligence technologies can help to suspicious cases that have signs of fraudulent activity (Drabiak & Wolfson, 2020). In summary, healthcare providers need to invest in reviewing and implementing the best practices to avoid harms associated with fraud and abuse.


Drabiak, K., & Wolfson, J. (2020). What should health care organizations do to reduce billing fraud and abuse? AMA Journal of Ethics, 22(3), 221-231.

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